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psnet.ahrq.gov/node/837963/psn-pdf
August 31, 2022 - (Note: subsequent medicolegal review by
experts revealed that there were scattered petechial hemorrhages
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psnet.ahrq.gov/web-mm/delayed-diagnosis-mesenteric-ischemia
March 31, 2021 - (Note: subsequent medicolegal review by experts revealed that there were scattered petechial hemorrhages
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psnet.ahrq.gov/node/865466/psn-pdf
March 27, 2024 - racial-ethnic-and-payer-disparities-adverse-safety-events-are-there-differences-across
indicators (e.g., postoperative sepsis infections, perioperative hemorrhage
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psnet.ahrq.gov/web-mm/stable-airway-fatal-airway-occlusion-after-inadequate-post-tracheostomy-care
June 28, 2023 - In the short term, emergent complications include tube decannulation, tube obstruction, and hemorrhage … tracheostomy tube can occur due to mucous plugging, clotted blood, and tube displacement. 4 Persistent bleeding
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psnet.ahrq.gov/node/49831/psn-pdf
June 01, 2018 - Other conditions, such as sepsis, respiratory failure, congestive heart failure, gastrointestinal hemorrhage
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psnet.ahrq.gov/periodic-issue/periodic-issue-447
July 10, 2024 - The surgical team had difficulty controlling bleeding and the patient left the operating room (OR) with … unit (PACU), the nurse called the attending physician three times to report hypotension and ongoing bleeding … The commentary discusses appropriate management of ongoing intraoperative and postoperative bleeding
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psnet.ahrq.gov/web-mm/delayed-sepsis-management-due-ambiguous-allergy
January 13, 2021 - Delayed Sepsis Management Due to Ambiguous Allergy
Citation Text:
Blumenthal K. Delayed Sepsis Management Due to Ambiguous Allergy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/sites/default/files/2020-03/final_spotlight_case_delays_in_the_ed_powerpoint_for_cme_review_03.09.2020.pdf
January 01, 2020 - Spotlight
Spotlight
Some Patients Can’t Wait:
Improving Timeliness of
Emergency Department Care
Source and Credits
• This presentation is based on the 2020 AHRQ WebM&M Spotlight
Case
○ See the full article at https://psnet.ahrq.gov/webmm
• Commentary by: David K. Barnes, MD, FACEP and Rita Chang, MD
○ Editor…
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psnet.ahrq.gov/web-mm/crushing-chest-pain-missed-opportunity
February 01, 2007 - Post-mortem autopsy revealed hemorrhage into the pericardium. … February 1, 2004
WebM&M Cases
Undiagnosed Vaginal Bleeding
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psnet.ahrq.gov/node/49431/psn-pdf
January 01, 2004 - Post-mortem autopsy revealed hemorrhage into the
pericardium.
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psnet.ahrq.gov/perspective/equity-patient-safety
September 24, 2024 - However, on some indicators (e.g., postoperative sepsis infections, perioperative hemorrhage), these
-
psnet.ahrq.gov/node/49792/psn-pdf
May 01, 2017 - Unfortunately, the
surgery was complicated and he had massive intraoperative bleeding.
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psnet.ahrq.gov/web-mm/diagnostic-delay-emergency-department
September 18, 2024 - Unfortunately, the surgery was complicated and he had massive intraoperative bleeding.
-
psnet.ahrq.gov/node/33708/psn-pdf
March 01, 2011 - are the words that put you into action, and we took him for the
CT and yes, it was a subarachnoid hemorrhage
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psnet.ahrq.gov/sites/default/files/2023-09/a_missed_bowel_perforation_-_the_importance_of_diagnostic_reasoning.pdf
January 01, 2023 - A regional program to educate primary care physicians on the clinical presentation of
subarachnoid hemorrhage
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psnet.ahrq.gov/node/846975/psn-pdf
March 28, 2023 - The initial core bundles were focused on hypertension, hemorrhage, and other clinical scenarios.
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psnet.ahrq.gov/web-mm/errors-sepsis-management
November 03, 2015 - SPOTLIGHT CASE
Errors in Sepsis Management
Citation Text:
Shimabukuro D. Errors in Sepsis Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/web-mm/missed-compartment-syndrome-after-steep-lithotomy-position-laparoscopic-gynecological
January 29, 2021 - thrombosis and put her on subcutaneous dalteparin at therapeutic dosing, to start later that evening if no bleeding … The fasciotomy procedure also has its own complications, such as bleeding and infection, and skin grafts … therapeutic anticoagulation so soon after a hysterectomy presented a significant risk of postoperative hemorrhage
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.45_slideshow.ppt
January 01, 2004 - Post-mortem autopsy revealed hemorrhage into the pericardium.
-
psnet.ahrq.gov/node/49483/psn-pdf
June 01, 2005 - A dose of 0.04 units/min was available for treating shock, and 0.4 units/min
for gastrointestinal hemorrhage … and variceal bleeding.